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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: - Board of Health
MAILING ADDRESS: Town of Barnstable
TELEPHONE NUMBER: P.O. Box 534
' CONTACT PERSON: Hyannis, MA 02601
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous
characteristics and must be registered when store
lease put a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) Drain cleaners
LAutomatic transmission fluid Toilet cleaners
/Engine and radiator flushes Cesspool cleaners
ydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
/Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
v Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
h0
TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
�J C) unsatisfactory- 4.Manufacturers ,-
COMPA NYL " (see"Orders") 5.Retail Stores
7 6.Fuel Suppliers
ADDRESS r r lass: 7.Miscellaneous
QlffANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground
IN OUT IN OUT IN OUT #&gallons 777 Test
Fuels:
Gasoline,Jet Fuel(A)
Diesel, Kerosene,#2 (B)
Heavy Oils: k-11
waste motor oil (C)
transmissioi! draulic
Synthetic Organics:
degreasers
Miscellaneous:
C
DISVOSAUREC=ON REMARKS:
1. Sanitary Sewage 2.Water Supply
O Town Sewer Public
Aron-site O Private
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES + NO O DE
O Holding tank:MDC 2��&�401
Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
- � YES NO
2.
P son( Interviewed Inspector Date
J ' COMPLIANCE: _ CLASS: 1, Marine,Cas Stations,Rcpair
-OWN OF B RNSTABLE 2. Printers �
Q satisfactory 3. Auto Body Shops
BOAR O F EALTH
O unsatisfactory- 4. Manufacturers
(see"Ord.ers") S. Retail Stores
COMPANY 6. Fuel Suppliers
ADDRESS _k �vc� Class• 7. Miscellaneous
QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)
MAJOR MATERIALS Case lots Drums AbOveTanks Undetgrouad Tanks
IN OUT JIN [OUT WOUT # & vellonse rest?
Fuels:
Gasoline, Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste -motor oil (C)
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
degreasers i
_ s _
Miscellaneous:
DISPOSAL RECLAMATION -'' " �,� KS:
1. Sanitary Sewage 2. Water ly `:N
O Town Sewer\ Public
On-site �O PP ivate
3. Indoor Floor Drains: YES �' NO
O Holding tank: MDC
O Catch basin/Dry well
ORDE
On-site system
4. Outdoor Surface drains-.YES V NO
Holding tank: MDC
O Catch basin/Dry well
1
On-site system
S. Waste .Transporter Licensed?
Name of EaUlk Destination Waste Product
12 .23 81 Person(s) Interviewed Inspector Date